GW1-2023-02421_Well Construction - GW1_20230404

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I
Cameron Bazin 14.WATER.ZONES I •
FROM TO DESCRIPTION
VJc1lCorttrdctarName i 5 ft G",, /��p I
R. ft
4515-A
NCWeII Contractor CerNeationNumber 15.OUTER CASING(for multi-cased wells)OR LINER fttfnp lienble)
Aqua Drill,Inc. 'FROM TO DLaMErER THICKNESS MATERIAL •
0 ft Q ft 4 in. PV
Companyllame.
16.INNER CASING OR TUBING(geothermal closed-loop)
. 2.Well Construction Permit#: FROM TO DIAMETER THCENESS MATERIAL
List all applicable well construction permits(i.e.UIC,Coang.State.Variance.etc) ft ft. ID.
3.Well Use(check well use): ft. ft. is
Water Supply Well: 1FRRSCREEN
M�O DIAMETER SLOTSIZE THICKNESS MATERIAL
*Agricultural OMunicipal/Pnblic ft ft. in.
N Geothermal(Heating/Cooling Supply) C3Residential Water Supply(single) ft - ft in. .
111 Industrial/Commercial DResidential Water Supply(shared) 18.GROUT •
NI Irri_ tion FROM TO •• MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: e) ft Z'L.ft [" ?n;05
V Monitoring URecovery ft ft. t
Injection Well: ft ft.
Aquifer Recharge DGTouadwaterRemediation
19.SAND/GRAVEL PACK(if applicable)
*Aquifer Storage and Recovery QSalinity Barrier FROM , TO MATERIAL EMPLACEMENT METHOD
jji Aquifer Test OStormwater Drainage ft ft
111 Experimental Technology OSubsidence Control ft ft
Geothermal(Closed Loop) ©ITracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO. DESCRIPTION(color,hardness.sail/rock type,grain sue etc.)
3 Geothermal(Heating/Cooling Return)
/Z Z nOther(explain under#21Remarks) Q ft 10 ft 5,1�1
4.Date Wells)Completed: 3(L(/ Well DV10 ft 2 ft: (2,0 .14 ir,. '.. t '„ —': 'V' 11,,.._1".
3.
5a.Well Location: ( ft. ft
(6 I ft AF'K „ tI.
Facility/Owner Nome Facility lD0(ifapplicable) R. ft'
756 w{/5 ( ANC--- AiOf IL ft ti.,:. .r4��,; i:?^L=
c, ?-'11±:=
Physical Address,City,and Tap I ft ft.
9 rep i.REMARKS
County Parcel ldeatificationNo.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(if well field,one lath is sufficient) 22.Certification:
6, V6 30 x y�V,76380v2 w 9 7/2/72-
6.Is(are)the well(s),EVPermanent or ( Temporary Signatur Cemfced Wef Contstctor D
By signing this form,I hereby cesit•that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: EYes or No with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
!phis is a repair,fill out blown well construction informs n and explain the native of the copy of this record has been provided to the well owner.
repair under 02I remarks section or on the back of this form
23.Site diagram or additional well details:
IL For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1GW-I is needed.Indicate TOTAL NUMBER of wells construction details.You may also attach additional pages ifnecessery.
• drilled: SUBMITTAL INSTRUCTIONS
n
9_Total well depth below land surface: 22. (ft-) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2QI00') construction to the following:
10.Static water level below top of casing. 5(9 (ft) Division of Water Resources,Information Processing Unit,
If-water level is above casing,use"i-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: / (in_) 24b.For Infection Wells: In addition to sending the form to the address in 24a
(' above,also submit one copy of this form within 30 days of completion of well
22.Well construction method: 6 i7�`��r 1 construction to the following:
(Le.auger,rotary,cable,direct push,etc.)-
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
. 13a.Yield(gpm) 20 Method of test: SI?j/' 24c.For Water Supply&Injection Wells: In addition to sending the form to
i /7J�— / the address(es) above, also submit one',copy of this form within 30 days of
13b.Disinfection type: I/ 1�f Amount: f 7 2✓ completion of well construction to the county health department of the county
where constructed.
I
Form GW-I - North CarolinaDepattment of Environmental Quality-Division of Prater Resources Revised 2 22 2016